Form SBA Form 2456 SBA Form 2456 8(a) Participant Benefits Report

OMB Approval #: 3245-

Expiration Date:

8(a) Participant Benefits Report

1. The 8(a) Participant is owned by:

 Indian Tribe  ANC  NHO  CDC

The information in this report is provided by the:

 8(a) Participant  Parent Corporation  Wholly-Owned Holding Company  Wholly-Owned Business Entity of Tribe

2. Name of 8(a) Participant: ____________________________________________________

Address: ______________________________________________________________________

City: _________________________ State:______________ Zip Code: __________________

3. Report Point of Contact (Name): _____________________________________________

Title: _______________________________________________________________________

Email Address: _________________________________________________________________

Business Telephone: __________________________ Fax Number: _______________________

SBA BENEFITS REPORTING CATEGORIES

Check the box to show areas of benefits provided for this reporting period.

Name of Community/Tribe: ___________________________________

 Category 1: Health, Social and Cultural Support ($ _________Estimate)

 Category 2: Education and Development ($ _________Estimate)

 Category 3: Lands ($ _________Estimate)

 Category 4: Economic and Community Development ($ _________Estimate)

 Category 5: Employment ($ _________Estimate)

 Category 6: Economic Benefits ($ _________Estimate)

 Category 7: Other (please specify) ($ _________Estimate)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Total estimated financial contribution from 8(a) Participant: $ _________________

Optional: Additional benefits provided by the Parent Corporation or Holding Company Level include:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Optional: Additional Parent Corporation or Holding Company Benefits: $ _________Estimate

BY SIGNING BELOW, I CERTIFY THAT ALL INFORMATION SUBMITTED IN THIS 8(A) PARTICIPANT BENEFITS REPORT IS TRUE, CORRECT AND ACCURATE. I UNDERSTAND THAT FALSE STATEMENTS CAN BE SUBJECT TO PROSECUTION UNDER 18 U.S.C. § 1001 AND OTHER STATUTES, CAN SUBJECT ME OR MY COMPANY TO TREBLE DAMAGES UNDER THE FALSE CLAIMS ACT, 31 U.S.C. §§ 3729–3733 OR SUSPENSION OR DEBARMENT, AND CAN RESULT IN THE TERMINATION OF MY COMPANY FROM THE 8(A) PROGRAM.

Print Name of Authorized 8(a) Participant Official: _________________________________________________________________________________

Title: ____________________________________________________________

Signature: ________________________________________________________ Date: ________________________________________

NOTE: 8(a) Participants may use a continuation sheet to provide any additional comments or information.

BENEFITS REPORTING FORM

Instructions:

Under 13 C.F.R. § 124.604 provides the following: As part of its annual review submission, each 8(a) Participant owned by a Tribe, Alaska Native Corporation (ANC), Native Hawaiian Organization (NHO) or Community Development Corporation (CDC) must submit to SBA information showing how the Tribe, ANC, NHO or CDC has provided benefits to the Tribal or native members and/or the Tribal, native or other community due to the Tribe’s/ANC’s/NHO’s/CDC’s participation in the 8(a) Business Development program through one or more firms. Nevertheless, submission of the Benefits Reporting Form is the primary responsibility of each 8(a) Participant and failure to comply may result termination for the 8(a) BD Program in accordance with 13 C.F.R. § 124.303.

Forms may be completed and submitted online at https://eweb.sba.gov/gls/dsp_login.cfm?SB=Y. However, the firm must submit a hard copy of the certification page only containing a “wet signature” of the President, Partner or Proprietor of the firm’s assigned Business Opportunity Specialist (BOS) located at the servicing District office.

Category 1 Examples: Health, Social and Cultural Support. Contributions (established or funded) in the following categories, as applicable, made for the benefit of the Native or other communities.

 Monetary donations or contributions

 Social programs

 Cultural programs (language revitalization, cultural camps, and after school programs).

 Beneficiary outreach and communication efforts (newsletters, websites, conferences, informational meetings, gatherings, and annual meetings of Native or community members).

 Death benefits (may include funeral benefits, life insurance proceeds, and potlatch funds).

Category 2 Examples: Education and Development

 Scholarship programs

 Life skills programs

 School program support

 Apprentice programs & intern programs

 Training programs (may include Board, Tribal Council, and management training and mentor programs)

Category 3 Examples: Lands

 Land management programs

 Subsistence programs (e.g., agriculture farming)

 Resource management and enforcement

 Water management

Category 4 Examples: Economic and Community Development

 Investment in new businesses

 Community infrastructure

 Support to small businesses or entrepreneurs

 Federal and state tax payments

 Housing assistance

 Energy assistance

Category 5 Examples: Employment

 Total number of jobs directly or indirectly created

 Employment assistance and support

Category 6 Examples: Economic Benefits

 Investment or payments made for the support of elder trusts or settlement trusts

 Investment or payments made towards permanent funds or restricted funds

 Dividends paid

 Increase in the value of the equitable interest

PLEASE NOTE: You are not required to respond to this or any collection of information unless it displays a currently valid OMB approval number. The total estimated time for responding to this request for information, including time to read instructions and compile the information needed to respond to questions or prepare reports, is 30 minutes. Comments on the burden estimate should be sent to U.S. Small Business Administration, Chief AIB, 409 3rd St., S.W., Washington, D.C. 20416 and Desk Officer for the U.S. Small Business Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. PLEASE DO NOT SEND COMPLETED FORMS TO OMB.

SBA Form 2456 __ (11/2015)

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